Treatment of mediastinitis: early modified Robicsek closure and pectoralis major advancement flaps.
BACKGROUND
The treatment of sternal wound complications is controversial. It is our practice to combine early aggressive debridement, a modified Robicsek sternal closure, and bilateral pectoralis major advancement flaps with or without closed irrigation in a single procedure. We reviewed our experience to determine the efficacy of this approach.


METHODS
Grade II to IV mediastinitis (dehiscence and infection) developed in 47 patients 3 to 14 days after routine open heart operations between 1990 and 1995. Culture-positive infection was identified in 60% (n = 28); 62% (n = 29) had septicemia. Thirty patients underwent incision, drainage, and surgical assessment of the wound. Once systemic signs of infection were under control (no pyrexia, normal white blood cell count), formal single-stage debridement of all infected soft tissues and bones was performed. Sternal stability was achieved using a modified Robicsek closure and bilateral pectoralis major advancement flaps. Seventeen patients were treated with staged procedures.


RESULTS
Early sternal closure and coverage with pectoralis major advancement flaps can be associated with a low mortality (0%), low morbidity (13%; n = 4: three superficial wound infections, one seroma), and shortened hospital stay (median, 22 days, compared with a median of 82 days in patients managed with conservative staged treatment; p < 0.05). Sternal stability with excellent functional and aesthetic results has been achieved in all patients.


CONCLUSIONS
The combination of aggressive early surgical debridement, sternal closure, and the placement of bilateral pectoralis major advancement flaps is a simple procedure associated with a low mortality and morbidity and a short hospital stay.
El Gamel
A
A
Cardiothoracic Unit, Wythenshawe Hospital, Manchester, United Kingdom.
Yonan
N A
NA
Hassan
R
R
Jones
M T
MT
Campbell
C S
CS
Deiraniya
A K
AK
Lawson
R A
RA
D000328:Adult; D000368:Aged; D001424:Bacterial Infections / Q000601:surgery; D006348:Cardiac Surgical Procedures; D003646:Debridement; D005260:Female; D006801:Humans; D007902:Length of Stay; D008297:Male; D008480:Mediastinitis / Q000382:microbiology / Q000601:surgery*; D008722:Methods; D008875:Middle Aged; D010369:Pectoralis Muscles / Q000601:surgery*; D011183:Postoperative Complications; D013249:Sternum / Q000601:surgery*; D013524:Surgical Flaps; D007507:Therapeutic Irrigation / Q000379:methods